What I’m Writing Today: CI5 Chapter 5

With a February 1 deadline looming, I’m in all out writing and editing mode. Today’s topic: Congruence. Below is an excerpt from the draft of the upcoming 5th edition of Clinical Interviewing. I gotta say, Congruence and Carl Rogers—good stuff—way better than any NFL playoff games:). I know, Empathy would be a little better, but you can’t always get what you want.

Here’s a glimpse of the opening of chapter 5: Evidence-Based Relationships in the Clinical Interview

In 1957, Carl Rogers made a bold declaration that has profoundly shaped research and practice in counseling and psychotherapy. He hypothesized in a Journal of Consulting Psychology article that no techniques or methods were needed, that diagnostic knowledge was “for the most part, a colossal waste of time” (1957, p. 102), and that all that was necessary and sufficient for therapeutic change to occur was a certain type of relationship between therapist and client.

Although we could go back further in time and note that Freud (of course) had originally discussed the potential value of therapeutic relationships, Rogers’s revolutionary statements refocused the profession. Until Rogers, therapy was primarily about theoretically-based methods, techniques, and interventions. After Rogers {{365 Rogers 1961; 690 Rogers 1957; 363 Rogers 1942;}}, we began thinking and talking about the possibility that it might be the relationship between client and therapist—not necessarily the methods and techniques employed—that produced therapeutic change.

For years, a great debate has fulminated within the counseling and psychotherapy disciplines {{499 Wampold 2001;}}. Norcross and Lambert (2011) refer to this debate as “The culture wars in psychotherapy” (p. 3). They describe it as a polarization or dichotomy captured by the question: “Do treatments cure disorders or do relationships heal people?” (p. 3). As academics and professional organizations have engaged in this debate, typically there has been little room for moderation and common sense. There have been assertions about the “rape” of psychotherapy as well as strong criticisms of practitioners who blithely ignore important empirical research {{4453 Baker,Timothy B. 2008; 5969 Fox, Ronald E. 1995;}}. The heat of this controversy continues, in part, because we live in a world with limited health care dollars . . . and the fight to determine which forms of therapy are included as “valid” and therefore reimbursable will likely continue.

But the focus of this chapter is about a part of the controversy that’s really no longer a controversy at all. In the past two decades excellent research and research reviews have settled at least one dimension of the argument. Evidence now overwhelming shows that therapy relationships do contribute to positive outcomes across all forms of therapy and setting {{2241 Goldfried 2007; 285 Sommers-Flanagan 2007; 4074 Norcross 2011;}}. The question is no longer a matter of whether the relationship in counseling and psychotherapy matters, but how much it matters.

This chapter focuses on what has come to be known as “evidence-based therapy relationships” {{5958 Norcross 2011;}}. Although organized around specific theories and supporting research, the chapter also provides clinical examples for how the theories and evidence translate into specific evidence-based relationship facilitating behaviors that occur in the clinical interview.

Thus, the relationship which I have found helpful is characterized by a sort of transparency on my part, in which my real feelings are evident; by an acceptance of this other person as a separate person with value in his own right; and by a deep empathic understanding which enables me to see his private world through his eyes. When these conditions are achieved, I become a companion to my client, accompanying him in the frightening search for himself, which he now feels free to undertake. (Rogers, 1961, p. 34)

Congruence

Congruence means that a person’s thoughts, feelings, and behaviors match. Based on person-centered theory and therapy, congruence is less a skill and more an experience. Congruent therapists are described as genuine, authentic, and comfortable with themselves. Congruence includes spontaneity and honesty; it’s usually associated with the clinical skill of immediacy and involves some degree of self-disclosure (see Chapter 4).

Congruence is complex and has been described as “abstract and elusive” {{5961 Kolden, Gregory G. 2011;}} (p. 187). The ability to be congruent includes an internal dimension that involves clients being in touch with their inner feelings or real self plus an external or expressive dimension that involves therapists’ being able to articulate their internal experiences in ways that clients can understand. The following excerpt from Rogers’s work illustrates these internal and external dimensions of experiencing and expressing congruence:

We tend to express the outer edges of our feelings. That leaves us protected and makes the other person unsafe. We say, “This and this (which you did) hurt me.” We do not say, “This and this weakness of mine made me be hurt when you did this and this.”

To find this inward edge of my feelings, I need only ask myself, “Why?” When I find myself bored, angry, tense, hurt, at a loss, or worried, I ask myself, “Why?” Then, instead of “You bore me,” or “this makes me mad,” I find the “why” in me which makes it so. That is always more personal and positive, and much safer to express. Instead of “You bore me,” I find, “I want to hear more personally from you,” or, “You tell me what happened, but I want to hear also what it all meant to you.” (pp. 390-391)

Rogers also emphasized that congruent expression is important even if it consists of attitudes, thoughts, or feelings that don’t, on the surface, appear conducive to a good relationship. He’s suggesting that it’s acceptable—and even good—to speak about things that are difficult to talk about. However, as you can see from the preceding example, Rogers expected therapists to look inward and transform their negative feelings into more positive external expressions of congruence.

Guidelines for Using Congruence

When discussing congruence, students often wonder how this concept is manifest. Common questions include:

Does congruence mean I say what I’m really thinking in the session?

If I feel sexually attracted to a client, should I be “congruent” and share my feelings?

If I feel like touching a client, should I go ahead and touch?

What if I don’t like something a client does? Am I being incongruent if I don’t express my dislike?

These are important questions. Watson, Greenberg, & Lietaer {{4387 Greenberg,Leslie S. 1998;}} provided one way for determining the appropriateness of therapist transparency or congruence. They wrote: “. . . it is not necessary to share every aspect of [your] experience but only those that [you] feel would be facilitative of [your] clients’ work” (p. 9). This is a good initial guideline: Would the disclosure be facilitative? In fact, sometimes, too much self-disclosure—even in the service of congruence or authenticity—can muddy the assessment or therapeutic focus. Perhaps the key point is to maintain balance; the old psychoanalytic model of therapist as a blank screen can foster distrust, reluctance, and resistance, while too much self-disclosure can distort and degrade the therapeutic focus {{2454 Farber 2006;}}.

Rogers also suggested limits on congruence. He directly stated that therapy wasn’t a time for clinicians to talk about their own feelings:

Certainly the aim is not for the therapist to express or talk about his own feelings, but primarily that he should not be deceiving the client as to himself. At times he may need to talk about some of his own feelings (either to the client, or to a colleague or superior) if they are standing in the way. (pp. 133–134) {{760 Rogers 1958;}}

Let’s say you’re working with a client and you feel the impulse to congruently self-disclose in the moment. If you’re not sure your comment will be facilitative or whether it will keep the focus on the client (where the therapy focus belongs), then you shouldn’t disclose. Additionally, you should discuss ongoing struggles with self-disclosure with your peers or supervisors because by so doing, you’ll deepen your learning about how best to be congruent with clients.

Since the 1960s, feminist therapists have strongly advocated congruence or authenticity in interviewer-client relations. Brody {{331 Brody 1984;}} described the range of responses that an authentic therapist might use:

To be involved, to use myself as a variable in the process, entails using, from time to time, mimicry, provocation, joking, annoyance, analogies, or brief lectures. It also means utilizing my own and others’ physical behavior, sensations, emotional states, and reactions to me and others, and sharing a variety of intuitive responses. This is being authentic. (p. 17)

Brody is advocating many sophisticated and advanced therapeutic strategies; but keep in mind that she’s an experienced clinician. Authentic or congruent approaches to interviewing are best if combined with good clinical judgment, which is obtained, in part, through clinical experience.